Too Many Chefs? When Teamwork Becomes Chaos

[Gizmopup1]

When does teamwork cross the line into craziness? I love it when people feel passion and become involved in my cases, but this past week has been a little overkill!

A great example of this was my last admission into Home Health services. The patient was a middle aged woman with few financial resources who was suddenly surprised with a serious cancer diagnosis. She is probably terminal, but is not yet ready to sign into Hospice services, and so is accepting Home Health services for support until the time she is ready to accept Hospice care.

The admission itself was very straightforward and revolved around starting nursing visits, sending a few DME items (she is still mostly independent but lives in a small space and doesn't want a lot of visual reminders of the decline to come), and then making initial contact with her attending and his staff.

And yet…..

How many people in my agency felt they needed to make it their business to send their opinions, advice and input to me on this case?

Yes, I know she is more appropriate for Hospice care, but the patient doesn't want it…

Yes, I know it is cheaper to send out a full orificenal of DME equipment all at the same time, but the patient doesn't want this…

Yes, I know her hospital report stated she has pain but she says it is managed…..

I felt I spent more of my time fielding busybody questions from staff at my agency than actual admission of the patient. And after fielding so many questions, I began to wonder if the people in my agency didn't trust me or my nursing expertise?

How do you handle situations like this in your practice? Is there a nice way to let people know that there are too many well-intended chefs dipping into the pot?

[nutella, MSN, RN]

I have a different perspective on this.

You are writing about home care and not specifically hospice - I assume your agency provides both services?

Because healthcare has become so complicated including different options for insurance coverage with managed medcare products and those hybrid SCO programs you naturally have more "cooks in the kitchen". This is the new challenge we are facing in healthcare and it comes from more pieces are being put in place, which are all interconnected and influencing each other. My opinion is that we need to learn to work within a healthcare system that is complex and somewhat "chaotic" at times because everything is interdependent.

It is also a good practice to allow for other people to give their input and to self-reflect upon their view.

Although their view or thoughts may be financially motivated, those thoughts can still be valid and lead to a different view or action - I am not saying it has to but it could. Unfortunately, our healthcare system has evolved in a way that we are also facing the fall-out of other people's financial interests. Example: If a patient has a managed medicare insurance like tufts preferred medicare - the physician group receives a lump sum of payment for all those enrolled for a year and they have to pay for all costs that occur for this patient. While it is a great step in holding providers accountable and theoretically should lead to savings through tight case management, it also means that those CM can be somewhat "pushy". They have an interest to enrolling high cost patients who are at the end of life and now spend $$$ for healthcare in a more futile manner in hospice. Because once a patient enrolls in hospice - they fall off the medicare preferred plan and that group does not have to pay for their healthcare anymore. So what it means is that people will continue to approach you for this and that to offer their input or ask questions.

I face the same in the inpatient setting and I would say that in the community I spend a certain amount of time with just those care coordination things.

It can be useful for you to have a running list of contact informations when the patient is insured with a managed plan and to have those case manager contact info available and just send them a message or leave a voice message after you admit somebody to home care with a short note. Personally, I find that when I am in contact with all other CM /liaisons we can put together a bigger picture and oftentimes all of us working together will lead to a better more connected care.